Abdominal and Pelvic Radiology Practice Questions

Q: Which pattern on an abdominal radiograph is suggestive of intestinal obstruction?

All of the above. In abdominal radiology, the diagnosis of intestinal obstruction relies on identifying specific gas and fluid patterns. The correct answer is **All of the above** because each option represents a classic radiological sign of different stages or types of obstruction. ### Explanation of Patterns: * **Step ladder pattern (Option A):** This is the hallmark of **Small Bowel Obstruction (SBO)**. It occurs when dilated loops of small bowel (diameter >3 cm) stack on top of each other. On an erect film, multiple air-fluid levels are seen at different heights within the same loop. * **String of beads pattern (Option B):** This sign is highly specific for **SBO with predominantly fluid-filled loops**. Small bubbles of gas get trapped between the valvulae conniventes (circular folds) along the superior wall of the bowel, resembling a string of pearls or beads. * **Diffuse ground glass opacity (Option C):** This occurs in **late-stage obstruction** or "closed-loop" obstruction where the bowel loops are entirely filled with fluid (the "fluid-filled" sign). The lack of gas results in a featureless, hazy, or "ground glass" appearance on the radiograph, often associated with ascites or strangulation. ### NEET-PG High-Yield Clinical Pearls: * **3-6-9 Rule:** Normal diameters are <3 cm (Small bowel), <6 cm (Large bowel), and <9 cm (Cecum). Anything above this suggests obstruction or ileus. * **Valvulae Conniventes vs. Haustra:** Small bowel folds (valvulae) cross the entire width of the lumen, whereas large bowel haustra do not. * **Coffee Bean Sign:** Pathognomonic for Sigmoid Volvulus. * **Bird’s Beak Sign:** Seen on barium swallow for Achalasia or barium enema for Volvulus.

Q: Tear drop bladder is seen in which condition?

Perivisceral hemorrhage with rupture. ### Explanation **Correct Answer: C. Perivisceral hemorrhage with rupture** The **"Tear-drop bladder"** is a classic radiological sign seen on a cystogram or CT scan. It occurs when the urinary bladder is compressed from both sides (extrinsic compression), causing it to elongate vertically and narrow horizontally, resembling a teardrop or a pear. The most common cause is a **pelvic hematoma** resulting from a pelvic fracture (perivisceral hemorrhage) [1]. While a hematoma without rupture can cause compression, the sign is most classically associated with significant trauma involving **pelvic floor disruption and hemorrhage**, often accompanied by bladder or urethral injury [1]. The accumulation of blood and fluid in the extraperitoneal space (Cave of Retzius) squeezes the bladder into this characteristic shape. [3, 4] **Analysis of Incorrect Options:** * **A. Hunner’s Ulcer:** This is a feature of Interstitial Cystitis. It is characterized by mucosal lesions and a "thimble bladder" (small capacity) due to chronic inflammation, not extrinsic compression. * **B. Tuberculosis:** Renal/Bladder TB leads to extensive fibrosis, resulting in a small, shrunken, and non-compliant bladder known as a **"Thimble bladder"** or "Golf-hole ureter." * **D. Perivisceral hemorrhage without rupture:** While any pelvic collection can compress the bladder, the classic "tear-drop" description in trauma surgery and radiology is most frequently linked to major pelvic ring disruptions where rupture/extravasation is a high-risk factor. **NEET-PG High-Yield Pearls:** * **Tear-drop Bladder:** Pelvic hematoma, pelvic lipomatosis, or bilateral iliac artery aneurysms. * **Thimble Bladder:** Tuberculosis, Schistosomiasis, or Radiation cystitis. * **Christmas Tree Bladder:** Neurogenic bladder (seen in Voiding Cystourethrogram - VCUG). * **Hourglass Bladder:** Congenital urachal diverticulum or sliding inguinal hernia containing the bladder.

Q: Gasless abdomen is a feature of which of the following conditions?

All of the above. **Explanation:** A **"Gasless Abdomen"** on an X-ray refers to the absence or marked deficiency of normal bowel gas patterns. This occurs when air cannot reach the distal intestines or when the abdominal cavity is relatively empty. 1. **High Intestinal Obstruction:** In conditions like esophageal atresia (without fistula) or pyloric stenosis with persistent vomiting, air cannot pass beyond the stomach or proximal duodenum. Consequently, the distal bowel remains collapsed and airless. 2. **Acute Pancreatitis:** While often associated with a "sentinel loop," severe acute pancreatitis can lead to a gasless abdomen due to persistent vomiting (clearing the gut of air) and the accumulation of significant inflammatory exudate/ascites that displaces or obscures bowel loops. 3. **Congenital Diaphragmatic Hernia (CDH):** In CDH (specifically the Bochdalek type), the abdominal viscera herniate into the thoracic cavity. This results in a "scaphoid abdomen" clinically and a gasless appearance on an abdominal X-ray because the intestines are simply not present in the abdominal compartment. **Clinical Pearls for NEET-PG:** * **Differential Diagnosis of Gasless Abdomen:** Also includes midgut volvulus (early stage), mesenteric ischemia, and "pseudo-gasless" abdomen (where bowel loops are entirely filled with fluid rather than air). * **CDH High-Yield:** The most common type is **Bochdalek** (posterolateral, usually left-sided). The primary cause of mortality is **pulmonary hypoplasia** and persistent pulmonary hypertension, not the hernia itself. * **X-ray Sign:** In high obstruction like Duodenal Atresia, look for the **"Double Bubble"** sign; if the obstruction is complete and proximal, the rest of the abdomen will be gasless.

Q: Which of the following is NOT a radiological sign of Crohn's disease?

Thumb printing. **Explanation:** The correct answer is **Thumb printing** because it is a classic radiological sign of **Ischemic Colitis**, not Crohn’s disease. **1. Why "Thumb printing" is the correct answer:** Thumb printing refers to smooth, rounded indentations on the intestinal wall seen on a barium study or CT. It is caused by **submucosal hemorrhage and edema**, most commonly seen in acute ischemic colitis. While it can occasionally appear in severe ulcerative colitis or infectious colitis, it is not a characteristic feature of Crohn's disease. **2. Analysis of Incorrect Options (Signs of Crohn's Disease):** * **String sign of Kantor:** This represents severe narrowing of the terminal ileum due to transmural inflammation and spasm. It appears as a thin, string-like opacification of the lumen. * **Creeping fat sign:** A pathognomonic CT/surgical finding where mesenteric fat wraps around the bowel wall due to chronic transmural inflammation. * **Cobblestone appearance:** This occurs due to deep longitudinal and transverse ulcerations (fissures) intersecting with islands of edematous, intact mucosa. **High-Yield Clinical Pearls for NEET-PG:** * **Skip Lesions:** Crohn's is characterized by discontinuous involvement (unlike the continuous involvement of Ulcerative Colitis). * **Proud Flesh:** Refers to the inflammatory polyps seen in Crohn’s. * **Comb Sign:** On CT, this refers to prominent, dilated mesenteric vessels (vasa recta) supplying the inflamed bowel segment. * **Lead Pipe Appearance:** A classic sign of **Ulcerative Colitis** (loss of haustrations), often tested as a distractor for Crohn's.

Q: A 58-year-old man presents with epigastric discomfort, early satiety, peripheral edema, and unintentional weight loss. Laboratory testing shows hypoalbuminemia. The upper GI contrast study demonstrates markedly enlarged, tortuous cerebriform gastric folds involving predominantly the body and fundus, with relative sparing of the antrum. What is the most likely diagnosis?

Ménétrier disease. Ménétrier disease is a protein-losing hypertrophic gastropathy characterized by markedly enlarged, cerebriform rugal folds, usually involving the gastric body and fundus with relative antral sparing. Excessive mucus production and loss of serum proteins through the gastric mucosa can cause hypoalbuminemia and peripheral edema. Gastric lymphoma may produce thickened folds or nodular masses but is less characteristically cerebriform and may impair or distort the stomach. Zollinger-Ellison syndrome can cause prominent folds due to acid-driven parietal cell hyperplasia, but it is typically associated with severe or recurrent peptic ulcers and diarrhea rather than protein-losing gastropathy. Linitis plastica produces a small, rigid, poorly distensible stomach with loss or effacement of normal folds rather than giant rugae.

Q: The investigation of choice for imaging of urinary tract tuberculosis is:

Intravenous urography. **Explanation:** **Why Intravenous Urography (IVU) is the Correct Answer:** Intravenous urography remains the **investigation of choice** for urinary tract tuberculosis (UTB) because it provides superior visualization of the early, subtle morphological changes in the pelvicalyceal system. UTB is characterized by "moth-eaten" calyces (due to erosions), infundibular stenosis, and phantom calyces (due to complete obstruction). IVU is highly sensitive in detecting these early mucosal irregularities and the functional status of the kidneys simultaneously. **Analysis of Incorrect Options:** * **Plain X-ray (KUB):** While it can show characteristic "putty kidney" (autonephrectomy) or globular calcifications in late stages, it cannot detect early mucosal changes or provide functional information. * **Ultrasound:** Useful for screening hydronephrosis or identifying renal masses, but it lacks the resolution to identify early papillary necrosis or subtle calyceal distortions typical of TB. * **Computed Tomography (CT):** Specifically, CT Urography is increasingly used and is better for evaluating the extent of extra-renal involvement. However, for the specific purpose of identifying early intraluminal/calyceal anatomy—the hallmark of UTB—classic IVU is traditionally favored in examinations. **High-Yield Clinical Pearls for NEET-PG:** * **Earliest Sign on IVU:** "Moth-eaten" appearance of the calyces due to papillary necrosis. * **Late Sign:** **Putty Kidney** (autonephrectomy) representing a non-functioning, calcified, shrunken kidney. * **Thimble Bladder:** A small-capacity, fibrotic bladder resulting from chronic TB cystitis. * **Beaded Ureter:** Multiple strictures along the ureter giving a beaded appearance. * **Gold Standard for Diagnosis:** Culture of three consecutive early morning mid-stream urine samples (Lowenstein-Jensen medium).

Q: A patient presents with mild abdominal pain and fluctuating bowel habits. The barium enema image is shown below. What is your diagnosis?

Diverticulosis. ***Diverticulosis*** - Barium enema shows characteristic **flask-shaped outpouchings** from the colon wall, representing diverticula filled with contrast. - Mild abdominal pain and **fluctuating bowel habits** are typical presentations of uncomplicated diverticulosis without inflammation. *Stricture colon* - Barium enema would show **segmental narrowing** of the colon lumen with smooth or irregular margins. - Typically presents with **obstructive symptoms** like severe cramping pain and constipation, not mild fluctuating symptoms. *Inflammatory Bowel Disease (IBD)* - Barium enema findings include **lead pipe colon** (loss of haustral markings) or **cobblestone mucosa** pattern. - Clinical presentation involves **bloody diarrhea**, weight loss, and systemic symptoms rather than mild pain. *Toxic megacolon* - Plain abdominal radiography shows **nonobstructive colonic dilation**, usually greater than 6 cm, with loss of haustral markings. - Contrast enema is **avoided** because of perforation risk. - Presents as a **medical emergency** with severe systemic toxicity, high fever, and signs of perforation risk.

Q: What is the characteristic 'crumbled egg appearance' in the liver associated with?

Hydatid liver disease. ### Explanation **Correct Answer: C. Hydatid liver disease** **Why it is correct:** Hydatid liver disease is caused by the parasite *Echinococcus granulosus*. The **"crumbled egg appearance"** (also known as the **"water lily sign"** or **"serpent sign"**) is a classic radiological finding on Ultrasound or CT. It occurs when the endocyst (the inner germinal layer) ruptures and detaches from the pericyst (the host-derived fibrous capsule). The collapsed, undulating membranes floating within the cyst fluid resemble a crumbled eggshell or a floating water lily. This finding is characteristic of **Gharbi Stage CE3** (transitional stage). **Why the other options are incorrect:** * **A. Hepatic adenoma:** Typically presents as a well-demarcated hypervascular mass, often associated with oral contraceptive use. It may show internal hemorrhage but not floating membranes. * **B. Chronic amoebic liver disease:** Usually presents as a "chocolate-colored" or "anchovy sauce" pus collection. On imaging, it appears as a poorly defined hypoechoic lesion, often in the right lobe, without internal membranes. * **D. Hemangioma:** The most common benign liver tumor. It shows a characteristic **peripheral globular enhancement** with centripetal fill-in on contrast CT/MRI, not a cystic appearance with membranes. **High-Yield Clinical Pearls for NEET-PG:** * **Gharbi Classification:** * CE1: Pure fluid (Simple cyst). * CE2: Daughter cysts (Honeycomb/Multivesicular appearance). * CE3: Detached membranes (Water lily/Crumbled egg appearance). * CE4/5: Calcified/Solid (Dead cyst). * **Treatment of Choice:** PAIR (Puncture, Aspiration, Injection, Re-aspiration) or surgical excision, always covered by **Albendazole**. * **Casoni Test:** An immediate hypersensitivity skin test (now largely replaced by ELISA).

Q: Colonic diverticulosis is best diagnosed by which imaging modality?

Barium enema. **Explanation:** **Colonic diverticulosis** refers to the presence of multiple outpouchings (diverticula) of the colonic mucosa and submucosa through the muscular layers. **Why Barium Enema is the Correct Answer:** Historically and for the specific diagnosis of "diverticulosis" (the presence of sacs without inflammation), **Barium Enema** is considered the gold standard and most sensitive imaging modality. It provides excellent mucosal detail, allowing for the visualization of the characteristic "saw-tooth" appearance of the colon and the filling of the diverticular sacs with contrast, which appear as flask-shaped outpouchings. **Analysis of Incorrect Options:** * **Colonoscopy (A):** While it can visualize diverticula, it is primarily used to rule out malignancy. It is less sensitive than barium studies for quantifying the extent of diverticulosis and carries a risk of perforation if acute inflammation is present. * **Nuclear Scan (B):** Technetium-99m labeled RBC scans are used to localize the site of **active diverticular bleeding**, not for the primary diagnosis of diverticulosis. * **CT Scan (D):** CT is the **investigation of choice for Acute Diverticulitis** (to look for wall thickening, fat stranding, or abscesses). However, for simple, non-inflamed diverticulosis, it is less sensitive than a barium enema in detecting small mucosal outpouchings. **NEET-PG High-Yield Pearls:** * **Most common site:** Sigmoid colon (due to high intraluminal pressure). * **Investigation of choice for Diverticulosis:** Barium Enema. * **Investigation of choice for Acute Diverticulitis:** Contrast-Enhanced CT (CECT). * **Contraindication:** Barium enema and Colonoscopy are **contraindicated** in the acute phase of diverticulitis due to the high risk of perforation.

Q: In case of suspected perforation, which radiological view is best?

Erect. **Explanation:** The primary radiological sign of a hollow viscus perforation is **pneumoperitoneum** (free intraperitoneal air). The **Erect Chest X-ray** (or Erect Abdomen) is the gold standard initial screening view because air, being lighter than fluid and solid organs, rises to the highest point in the peritoneal cavity. In the upright position, this air collects under the diaphragm, appearing as a thin, radiolucent crescent (the "crescent sign"). As little as 1–2 ml of free air can be detected on a well-taken erect film. **Analysis of Options:** * **A. Erect (Correct):** Gravity allows air to rise and contrast against the undersurface of the diaphragm and the density of the liver/spleen. * **B. Supine:** In this position, air collects anteriorly and spreads out. It is difficult to visualize unless there is a large volume, where it may show the **Rigler sign** (gas on both sides of the bowel wall) or the **Football sign**. * **C. Lateral Decubitus:** This is the alternative if the patient is too ill to stand. The patient lies on their **left side** (Left Lateral Decubitus) so that air rises and collects between the liver and the right abdominal wall. While sensitive, it is secondary to the erect view. **Clinical Pearls for NEET-PG:** * **Most sensitive view:** The **Left Lateral Decubitus** is technically more sensitive than the erect view for very small amounts of air, but the **Erect Chest X-ray** remains the "best" and most common initial investigation. * **Gold Standard Investigation:** While X-ray is the initial step, **NCCT (Non-Contrast CT) Abdomen** is the most sensitive overall imaging modality for detecting pneumoperitoneum. * **Positioning Tip:** For maximum sensitivity, the patient should remain in the erect or decubitus position for **10–20 minutes** before the film is taken to allow air to migrate.

Question 1

Which pattern on an abdominal radiograph is suggestive of intestinal obstruction?

Accepted Answer

All of the above

Answer

Step ladder pattern

Answer

String of beads pattern

Answer

Diffuse ground glass opacity

Question 2

Tear drop bladder is seen in which condition?

Accepted Answer

Perivisceral hemorrhage with rupture

Answer

Hunner's ulcer

Answer

Tuberculosis

Answer

Perivisceral hemorrhage without rupture

Question 3

Gasless abdomen is a feature of which of the following conditions?

Accepted Answer

All of the above

Answer

High intestinal obstruction

Answer

Acute pancreatitis

Answer

Congenital diaphragmatic hernia

Question 4

Which of the following is NOT a radiological sign of Crohn's disease?

Accepted Answer

Thumb printing

Answer

String sign of Kantor

Answer

Creeping fat sign

Answer

Cobblestone appearance

Question 5

A 58-year-old man presents with epigastric discomfort, early satiety, peripheral edema, and unintentional weight loss. Laboratory testing shows hypoalbuminemia. The upper GI contrast study demonstrates markedly enlarged, tortuous cerebriform gastric folds involving predominantly the body and fundus, with relative sparing of the antrum. What is the most likely diagnosis?

Accepted Answer

Ménétrier disease

Answer

Gastric lymphoma

Answer

Zollinger-Ellison syndrome

Answer

Linitis plastica

Question 6

The investigation of choice for imaging of urinary tract tuberculosis is:

Accepted Answer

Intravenous urography

Answer

Plain X-ray

Answer

Ultrasound

Answer

Computed tomography

Question 7

A patient presents with mild abdominal pain and fluctuating bowel habits. The barium enema image is shown below. What is your diagnosis?

Accepted Answer

Diverticulosis

Answer

Inflammatory Bowel Disease (IBD)

Answer

Toxic megacolon

Answer

Stricture colon

Question 8

What is the characteristic 'crumbled egg appearance' in the liver associated with?

Accepted Answer

Hydatid liver disease

Answer

Hepatic adenoma

Answer

Chronic amoebic liver disease

Answer

Hemangioma

Question 9

Colonic diverticulosis is best diagnosed by which imaging modality?

Accepted Answer

Barium enema

Answer

Colonoscopy

Answer

Nuclear scan

Answer

CT scan

Question 10

In case of suspected perforation, which radiological view is best?

Accepted Answer

Erect

Answer

Supine

Answer

Lateral decubitus

Answer

None

Abdominal and Pelvic Radiology — MCQs

Abdominal and Pelvic Radiology — MCQs

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